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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal <br />_ �`' <br />C: P.O. Box 1758 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. A L-J <br />Sample Date t' ' Time %1:1 S <br />Collected By n•1 rt c L ' l <br />Field Custodian L } 4 f <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />a.vaacr <br />1 I of <br />V111011C AmbummuuQ <br />r"ei f , — n <br />Lab. No.(s) <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: 06— <br />L Sample Type: Air Water Soil Other (specify): <br />2. Analysis – Test series requested: u ble <br />3. <br />4. <br />S. <br />Field Data – Preservation: 10 C h1 �• �( 'r,� + t��» <br />Date analysis required by (if not Holding Time): <br />Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial ( } and explain below. <br />COMMENTS – Explanation of noted items: <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( ) NO ( ) If NO, explain: <br />QAC <br />Date <br />V s# <br />0 <br />Page 30 of 30 <br />